1. Module 4 Rotavirus vaccine administration
Training for rotavirus vaccine introduction
Module 4
Rotavirus vaccine administration

2. Learning objectives
At the end of the module, the participant will be able to:
Identify the necessary steps to assure good vaccine quality
Describe the method to administer the vaccine
Describe special considerations for outreach
Duration
45’

3. Key issues 1 2 3 4 How to check the quality of the vaccine?
How to prepare for vaccination? 2
How to administer the vaccine? 3
To the facilitator:
Explain to the participants the key issues raised in this module.
You have infants to vaccinate, what are you going to do first?
We will provide you with answers to the following questions:
How to check the quality of the vaccine?
How to prepare for vaccination?
How to administer the vaccine?
What to do if infant spits part of the vaccine out?
What to do if the infant spits part of the vaccine out? 4

4. How to check the quality of the RotarixTM vaccine? (1/2)
Before administering RotarixTM vaccine, always check the Vaccine Vial Monitor (VVM) on the tube cap
Stage 1: Vaccine OK
Stage 2: Vaccine OK but use first
Stage 1: Do not use the vaccine
To the facilitator:
Explain to the participants how to check and interpret the Vaccine Vial Monitor (VVM).
The vaccine vial monitor (VVM) is a round disc of heat-sensitive material placed on a vaccine vial to register cumulative heat exposure.
The inner square is chemically active and changes color irreversibly from light to dark with exposed to heat over time.
By comparing the color of the inner square to the reference color, a health worker can determine whether or not the vaccine has been exposed to heat.
Thanks to the VVM, important decisions about which vaccines to use or to discard are now clear. If the inner square matches or is darker then the outer ring, discard the vaccine. 4

5. How to check the quality of the vaccine? (2/2)
Before administering the RotarixTM vaccine, always check the expiration date on the tube cap
To the facilitator:
Explain to the participants how and where to check the expiration date.
It is important to understand that VVM does not provide information about vaccine potency.
The VVM may be ok (which means the inner square is lighter than the outer circle), but the vaccine may be beyond the expiration date.
So always check the expiration date on the vaccine vial before using it.
The expiration date is mentioned clearly on the cap. 5

6. What should you do in this scenario?
The vaccine vial monitor shows that the inner square is lighter than
the ring (=  stage 2).
What should you do?
To the facilitator:
Read the situation and question to the participants.
This question will test if participants understand what to do if the vaccine vial monitor shows that the inner square is still lighter than the ring.
Response:
Use these vaccines first, as their VVM has already started to change. 6

7. How to prepare for vaccination? (1/4)
Pull off the cap from the tube of RotarixTM vaccine
Clear the fluid from the upper part of the tube by tapping the tube
To the facilitator:
Explain to the participants how to prepare the vaccine.
Step 1/4:
Pull off the cap from the RotarixTM tube. Clear the fluid from the upper part of the tube by tapping the tube. 7

8. How to prepare for vaccination? (2/4)
Turn the cap upside-down and place the cap vertically onto the tip seal
Insert the tip seal into the small hole in the top of the cap
To the facilitator:
Explain to the participants, how to prepare the vaccine.
Step 2/4:
Turn the cap upside-down and place the cap vertically onto the tip seal.
Insert the tip seal into the small hole in the top of the cap. 8

9. How to prepare for vaccination? (3/4)
Twist the cap in the direction of the arrow (clockwise) to remove the tip seal
Do not snap off tip seal as may fall inside the tube
To the facilitator:
Explain to the participants, how to prepare the vaccine.
Step 3/4:
Twist the cap in the direction of the arrow (clockwise) to remove the tip seal.
Do not snap off tip seal: It may fall into tube. 9

10. How to prepare for vaccination? (4/4)
Ensure that a hole clearly appears at the top of the tube
Ensure that the detached tip seal is inside the top of the cap
To the facilitator:
Explain to the participants how to prepare the vaccine.
Step 4/4:
Ensure that a hole clearly appears at the top of the tube and that the detached tip seal is inside the top of the cap.
Very important to know that: The vaccine must be discarded if the tip seal falls into the tube. 10

11. What should you do in this scenario?
While opening the RotarixTM tube to administer the vaccine, the tip seal is accidentally pushed into the tube solution.
What should you do?
To the facilitator:
Read the situation and question to the participants.
This question will test if participants understands what to do in case the tip seal is accidentally pushed into the tube.
Response:
In the event that the tip seal is accidentally pushed into the tube, discard the RotarixTM vaccine tube and use another tube to vaccinate the infant.
This is just a precaution, since it is unlikely that the tip seal could be expelled from the tube while administering the RotarixTM vaccine. 11

12. Can rotavirus vaccine (RotarixTM) be given at the same time as other childhood vaccines?
RotarixTM, as well as other rotavirus vaccines, can be administered with any of the following routine childhood vaccines without interfering with their effectiveness:
Diphtheria–tetanus–pertussis vaccine (DTP)
Haemophilus influenzae type b vaccine (Hib)
Inactivated polio vaccine (IPV)
Hepatitis B vaccine
Pneumococcal vaccine
Oral polio vaccine (OPV)
Give the rotavirus (and OPV) vaccine first, then administer other injectable childhood vaccines
To the facilitator:
Explain to the participants that rotavirus vaccines can be given with routine childhood vaccines.
Rotarix™ can be given with any of the following routine childhood vaccines without interfering with their effectiveness, during the same visit.
• Diphtheria–tetanus–pertussis vaccine (DTP)
• Haemophilus influenzae type b vaccine (Hib)
• Inactivated polio vaccine (IPV)
• Hepatitis B vaccine
• Pneumococcal vaccine
Oral polio vaccine
Give the Rotavirus (RotarixTM) vaccine first, then administer other injectable childhood vaccines. As a general rule its better to give oral vaccines first when the infant is still calm and then give injectable vaccines.
Additionally, as the OPV vaccine has a bitter taste, but is of a smaller quantity than the Rotarix vaccine (0.1 ml versus 1.5 ml), administer the bitter (OPV) vaccine first, then give the infant the sweeter tasting vaccine (Rotarix) second to take the bitter taste away. 12

13. What should you do in this scenario?
The infant is 6 weeks old. You give him/her OPV, rotavirus and pentavalent vaccines.
In which order should you give the vaccines?
To the facilitator:
Read the situation and question to the participants.
This question will test if participants understand when to administer the vaccine.
Response:
Administer the vaccines in the following order:
Give the OPV and Rotavirus (Rotarix™) oral vaccines first, then administer the injectable childhood vaccines.
As a general rule it is better to give oral vaccines while the infant is still calm and then give the injectable vaccines.
Additionally, as the OPV vaccine has a bitter taste, but is of a smaller quantity than the RotarixTM vaccine (0.1 ml versus 1.5 ml), administer the bitter (OPV) vaccine first, then give the infant the sweeter tasting vaccine (Rotarix™) second to take the bitter taste away. 13

14. How to position the infant for rotavirus vaccination?
The infant should be seated in a semi reclining position to take the vaccine orally
To the facilitator:
Explain to the participants how to position the infant before administering the vaccine.
The infant should be seated in a semi reclining position (i.e. normal feeding position). 14

15. How to position the vaccine?
Open the infant’s mouth by gently pressing the cheeks together
Angle the tube towards the inner cheek
To the facilitator:
Explain to the participants how to position the vaccine in the infant’s mouth.
Gently squeeze the infant's cheeks to open the mouth.
Put the tube towards the inner cheek.
Make every effort to aim the tube containing the vaccine down one side and toward the back of the infant's mouth.
Do not put the tube too far back in the mouth. Never place the tube into the center of the mouth to prevent the risk of choking. 15

16. How to administer the vaccine?
Administer the RotarixTM vaccine by pressing the tube
Squeeze the tube slowly
Make sure the infant is swallowing the vaccine
Hold the cheeks together and stroke him/her under the chin to help with swallowing
To the facilitator:
Explain to the participants how to administer the vaccine.
As you would do for the oral polio vaccine (OPV)
Gently squeeze the infant’s cheeks to open the mouth.
Then, you can administer the entire content of the tube by gently squeezing the tube several times.
Make sure the infant is swallowing the vaccine to prevent buildup in the mouth.
Gently hold the cheeks together and stroke him/her under the chin to help with swallowing.
Afterwards, dispose of the RotarixTM vaccine tube along with other medical waste.
You can notice that a residual drop may remain in the tip of the tube. 16

17. What should you do in this scenario?
Is the infant in the right position to be vaccinated?
To the facilitator:
Read the situation and question to the participants.
This question will test if participants understand the correct position the infant must be in for rotavirus vaccination.
Response:
Yes. The infant should be seated in a semi reclining position (i.e. normal feeding position). 17

18. What to do if the infant spits out part of the rotavirus vaccine (RotarixTM)?
A dose of rotavirus vaccine (RotarixTM) is larger than a dose of oral polio vaccine
Rotarix™ = 1.5 ml; Polio = 0.1ml
To prevent spitting
Open the infant’s mouth by gently pressing the cheeks together
Place the tip of the tube towards the inside of the infant’s cheek
Slowly administer the vaccine in small portions
A replacement dose is not needed if an incomplete dose is administered for any reason
e.g. infant spits or regurgitates the vaccine
To the facilitator:
Explain to the participants how to manage with partial vaccination.
The rotavirus vaccine dose quantity is larger than that of oral polio vaccine (Rotarix™ = 1.5 ml, OPV = 0.1 ml) and some infants may find it a bit difficult take the full dose all at once. However, countries that have been using this vaccine have not reported many cases of spitting.
Spitting can be prevented if the health workers spend enough time administering the vaccine to the infant and encouraging the infant to swallow.
How to prevent spitting:
Open the infant’s mouth by gently pressing the cheeks together
Place the tip of the tube towards the inside of the infant’s cheek
Slowly administer the vaccine in small portions
A replacement dose is not needed if an incomplete dose is administered for any reason, e.g. infant spits or regurgitates the vaccine. 18

19. How many vials to take for outreach?
Rotavirus vaccine can be given at the same time as other vaccines in the routine programme
For outreach take the same number of doses of rotavirus (Rotarix™) vaccine as for pentavalent vaccine
Unopened and sealed rotavirus tubes brought back from outreach should be immediately kept in the refrigerator for use in the next session, provided that the VVM and expiry date have not passed the discard point and date
To the facilitator:
Explain to the participants how many vials to take.
Rotavirus vaccine can be given at the same time as pentavalent vaccine (DTP-HepB-Hib), PCV, OPV or any other vaccine in the routine programme.
A simple method to calculate the number of (RotarixTM) tubes that need to be taken, is to take the same amount as single dose Penta vials, even though Penta vaccine has a three-dose schedule and rotavirus vaccine has a two-dose schedule.
As an example, in a country using 1 dose Penta vials and 1 dose Rotavirus (Rotarix™) tubes, you would need to take 1 tube of Rotavirus (Rotarix™) for each Penta vial.

20. Key messages
Check and interpret vaccine vial monitor and check expiration date on the tube cap before giving the rotavirus vaccine (RotarixTM)
When opening the rotavirus vaccine (RotarixTM) tube, twist the tube cap clockwise to remove the tip seal
Give the oral vaccines – OPV and RotarixTM - first, then administer the injectable vaccines
Give OPV before Rotarix™ so the “sweeter” vaccine (Rotarix™) takes away the taste of the “bitter” OPV vaccine
RotarixTM vaccine dose quantity is larger than that of OPV (1.5 ml vs. 0.1ml). To make sure that infants take the full dose at once
Seat the infant in a semi-reclining position, open the infant’s mouth by gently pressing the cheeks together, properly place the tip of the tube towards the inside of the infant’s cheek and slowly administer the vaccine in small amounts
If the infant spits out some or all of the vaccine, the dose does not need to be given again during that visit
To the facilitator:
Explain to the participants that this is the main information to keep in mind. 20

21. End of module for your attention! Thank you To the facilitator:
This is the end of the module.
You have been introduced to “Rotavirus vaccine administration” module.
The following module is titled “Recording and monitoring uptake of rotavirus vaccine”.
Thank you for your attention!